VOL: 99, ISSUE: 40, PAGE NO: 20
Russell D. Metcalfe-Smith, SRPara, is community resuscitation officer, London Ambulance Service NHS Trust
Resuscitation is a technique used by professional health care staff, as well as members of the public. It is essential for all health care professionals to be able to perform basic life support, and training for staff who are commonly involved with resuscitation attempts must take place on a regular basis.
Duty of care
The NMC code of professional conduct (2002) states: ‘In an emergency in or outside of the work setting you have a professional duty to provide care. The care provided would be judged against what could reasonably be expected from someone with your knowledge, skills and abilities, when placed in those particular circumstances.’ This statement has implications for all nurses. As health care professionals, we must ensure that we remain competent in order to be able to deliver this basic level of care.
Cardiac arrest training
The Resuscitation Council UK publishes guidelines that are adhered to in the UK (Resuscitation Council UK, 2002). These are based on best available evidence and are altered only when there is good evidence to suggest the need for amendment.
Resuscitation officers are now a permanent feature in many UK hospitals. They are health care professionals with a critical care background, usually a nurse, paramedic or operating department practitioner. The role of resuscitation officers will depend on where they work and will vary considerably. Many are part of the hospital cardiac arrest team, auditing cardiac arrests and providing emergency training to colleagues.
A new development has been the introduction of the community-based resuscitation officer. The London Ambulance Service NHS Trust has endeavoured to improve survival from cardiac arrest in the community by, among other measures, employing resuscitation officers from among a range of professionals - nurses, paramedics or operating department practitioners. The community-based resuscitation officers are committed to ensuring that professionals in the community can provide the same level of support and training as those in hospital.
Primary care trusts are making use of this service to meet training requirements, such as using automated external defibrillators in the community, resuscitation at varying levels and clinical skills training. The benefit of community-based resuscitation officers is that the London ambulance service is providing a team of professionals with wide-ranging experiences in emergency care (London Ambulance Service NHS Trust, 2003).
Improving the chance of survival
Ideally, a patient who is critically ill must be identified in the shortest possible time and corrective action taken. For every minute that passes after a patient goes into cardiac arrest their chance of survival decreases by seven to 10 per cent until a defibrillator arrives (Metcalfe-Smith, 2003). As in any situation, prevention is the best course of action, but this is not always possible.
A patient who has suffered sudden cardiac arrest must receive effective treatment rapidly. The method of delivering such care, developed by the American Heart Association, is called the chain of survival and comprises four links:
- Early access to emergency help;
- Rapid cardiopulmonary resuscitation;
- Rapid defibrillation;
- Early advanced care.
A development has been the incorporation of early recognition as an important element of the chain of survival.
Early recognition is an essential element in any emergency. Understanding when a patient is critically unwell, and acting promptly, can stop their condition deteriorating.
Specific criteria govern the need to call for further help, regardless of whether the health care professional works in the community or in a hospital, such as a sustained change in heart rate or level of consciousness. But this could also include chest pain that persists for more than 15 minutes and is not relieved by nitrates.
Stopping a cardiac arrest occurring in the first place is obviously the route of choice. It is important to note that a pattern of deterioration in the hours and days before a cardiac arrest is common (Franklin and Matthew, 1994).
Early access to emergency help
In the case of a real emergency in the community, the ambulance service must be called via the 999 system. In the hospital setting, asking for appropriate help may stop a patient’s condition deteriorating. In the case of a cardiac arrest, the arrest team must be called immediately.
Early basic life support
If a cardiac arrest occurs in the community, the patient must be moved onto a hard surface and placed on his or her back. Quickly make the environment appropriate for performing life-saving procedures. This could mean moving chairs or tables.
In the hospital environment, remove the headboard from the bed and adjust the mattress, so it is suitable for performing chest compressions, and move the cardiac arrest trolley next to the patient’s bed. These procedures should take a very short time when you work effectively as a team.
The only proven way to ‘restart’ a patient’s heart is with rapid defibrillation for patients in ventricular fibrillation and pulseless ventricular tachycardia. In the community, approximately 85 per cent of patients experiencing cardiac arrest present with a heart rhythm requiring defibrillation.
In hospital, there are fewer patients presenting with a shockable rhythm, but their aetiology is usually different. In any cardiac arrest, however, defibrillation must occur as quickly as possible. Patients should ideally not have to wait for the arrival of the cardiac arrest team or ambulance for this to occur.
Early advanced life support
The final stage in the management of a cardiac arrest is usually when the cardiac arrest team arrives in the hospital or the paramedics arrive in the community.
The advanced life support stage continues until resuscitation efforts are terminated or the patient is transferred to intensive care. Good basic life support and defibrillation are the top priority. There is no robust data to show that drugs used in cardiac resuscitation alter long-term outcomes (Resuscitation Council UK, 2002).
Progressing through these four steps in the shortest possible time can mean the difference between patients dying or recovering. If any step fails to take place, the patient’s chance of recovery reduces dramatically.
Automated external defibrillation
The defibrillators normally used by nursing and medical staff are manual defibrillators. Their use is generally restricted to specialist coronary care nurses, medical staff, and paramedics, as this is specialist equipment that requires training to use. The equipment enables the operator to diagnose the cardiac arrest rhythm and decide whether to administer an appropriate shock. This requires constant training updates and, ideally, patient exposure.
The advent of automated external defibrillators should change the need for specialist training and designated operators. The equipment is simple to use and involves the following:
- The first step is to confirm that the patient is in cardiac arrest;
- The second is turn the machine on;
- Finally, all that is required is to follow the instructions given by the machine.
The introduction of automated external defibrillators means that defibrillation can now be started before the arrival of the cardiac arrest team. Many hospitals are installing automated external defibrillators on general medical and surgical wards to enable anyone trained to use them to rapidly defibrillate a patient.
The Resuscitation Council UK recommends six-monthly refresher training for staff using these devices. This can be provided for hospital staff by their resuscitation officer and in the community by the community-based resuscitation officers.
Basic life support: the UK guidelines
Training should be based on the guidelines drawn up by the Resuscitation Council UK (2000) (Fig 1). These follow an easy-to-use assessment technique commonly known as DR ABC. This stands for Danger, Response, Airway, Breathing and Circulation.
On discovering a patient in a collapsed state, assess the potential risk to yourself as the health care professional. Risk assessment should include environmental issues, patient location and the presence of other people. In the hospital environment, this could extend to slippery floors, bedside tables and sharps.
Community nurses need to be aware of the patient’s location. Spending a few moments preparing the environment before starting resuscitation may make this physically demanding technique easier. Patients who lose their breathing and circulation must receive good effective chest compressions on a hard surface.
Check to see if a patient is responsive when you enter the room by calling loudly: ‘Hello, can you hear me, open your eyes.’ Be careful when approaching a patient: remain at arm’s length in the first instance, as the patient may be startled by your approach. Gently shake the patient if there is no response to determine whether he or she is conscious or unconscious. If there is no response, the patient can be regarded as unconscious. It is important at this stage, if you have not already done so, to shout for help.
Have a look inside the patient’s mouth: if an object can be seen and can be removed safely, do so. If the object is at the back of the throat do not try to remove it. Be extremely careful when you put your fingers in the patient’s mouth. If there is nothing visibly obstructing the patient’s airway, perform a head tilt and chin lift.
If the potential for cervical spine injury is evident, use the jaw-thrust technique to maintain cervical spine neutrality. Opening an airway is essential: without this, you cannot ventilate the patient. In hospital, suction equipment to clear an airway should be available to staff. Airway adjuncts can be helpful but are not always essential.
In the community, if the patient is not breathing and no help has arrived, you must leave the patient and go to call 999 for an ambulance immediately. State clearly your exact location and explain that the patient is not breathing. Health professionals must remember that the only proven way of restoring a perfusing rhythm is with defibrillation - basic life support only ‘buys’ time (Resuscitation Council UK, 2000).
In hospital, if a patient’s breathing and circulation are absent, call the cardiac arrest team and immediately collect the defibrillator. Apply it and, if you are trained and authorised, defibrillate the patient. If there is any delay in collecting the equipment, ventilations and compressions must begin (Leah and Coats, 1999).
Once appropriate help and procedures have taken place, ventilations must commence. You have up to five attempts to produce effective chest rise. Consideration at this point must be given to use of a face mask or bag valve mask for professionals trained in their use. The patient must always be ventilated with high-flow oxygen, if available.
No health care professional should be expected to perform mouth-to-mouth resuscitation in the work environment: staff who may need to perform resuscitation should have access to a barrier device.
The use of the bag valve mask is ideally a two-person technique. If two people are not available, patients may be ventilated more effectively with a face mask. This can also be connected to high-flow oxygen and will deliver in the region of 50 per cent oxygen to a patient being ventilated (Martin, 1993).
Once the patient has been ventilated, assess their circulation. Staff in a hospital setting will have assessed any absence earlier.
Health care professionals are taught to check for pulse, with the carotid artery being the easiest to access. The pulse check should take 10 seconds to determine presence or absence. Members of the public are no longer taught to perform pulse checks, but are told instead to look for signs of life. The change was prompted by a study that found that even health care professionals had difficulty determining whether a patient’s pulse was present (Ochoa, 1998). If health staff experience such problems, it is unfair to expect a lay person to do this assessment. Assessment of circulation by lay people includes checking for breathing, coughing and movement, but no pulse check.
If no circulation can be determined after 10 seconds, chest compressions must commence to support the patient’s circulation. Failure to begin chest compressions or to make an incorrect diagnosis would result in permanent neurological deficit and probably death.
Compress the chest about 4-5cm 15 times, give two ventilations and continue this sequence until appropriate help arrives.
Terminating resuscitation efforts
In basic life support, the standard guidelines for termination of resuscitation are:
- Return of spontaneous circulation;
- Arrival of cardiac arrest teams or ambulance crews;
- If you become exhausted.
Termination of resuscitation attempts is usually determined by the most senior appropriate member of staff present, but the decision should involve the whole team. Any disagreement must be addressed and appropriate action taken in the best interests of the patient. In the community, paramedics follow standard guidelines for terminating resuscitation attempts.
When delivered promptly, resuscitation can save the lives of many patients in cardiac arrest. Following the chain of survival principles ensures rapid intervention and increases the chance of a positive outcome.
All health care professionals with a responsibility for patients must be offered regular training updates in resuscitation. As registered health care professionals, we all have a responsibility to ensure we remain competent to perform resuscitation.